New Patient Registration

Please select the practice location most relevant to this Online Form submission:

Title

First Name

Surname

Previous Surnames

Gender

Date of BirthDay / Month / Year

NHS Number (if known)If you know your NHS Number, please provide it

Town and Country of birth

Date you first came to live in UK (Enter N/A if you have always lived in the UK)DD/MM/YYYY

Home Address

Postcode

Telephone Number

E-mail Address

Is this a temporary registration?

Please help us trace your previous medical records by providing the following information

Your previous address in UK

Name of previous GP practice while at that address

Address of previous GP practice

If you are from abroad

Your first UK address where registered with a GP

If previously resident of UK, date of leavingDD/MM/YYYY

Were you ever registered with an Armed Forces GP

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas:

Address Before Enlisting

Service or Personnel Number

Enlistment DateDD/MM/YYYY

Discharge Date (if applicable)DD/MM/YYYY

Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services

If you need your doctor to dispense medicines and appliances

I live more than 1.6km in a straight line from the nearest chemist.

I would have serious difficulty in getting them from a chemist.

Not all doctors are authorised to dispense medicines

For all patients who are not ordinarily resident in the UK

Anybody in England can register with a GP practice and receive free medical care from that practice.

However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.

Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice.

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP pract

I am not ordinarily resident in the UK

Please tick one of the following boxes

I understand that I may need to pay for NHS treatment outside of the GP practice

I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge (“the Surcharge”), when accompanied by a valid visa. I can provide documents to support this when requested

I do not know my chargeable status

A parent/guardian should complete the form on behalf of a child under 16.

Non-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) Details And S1 Forms

Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have a GHIC or EHIC issued by the UK.

I have a non-UK EHIC or PRC

Please enter details from your EHIC or PRC below

Country Code

Name

Given Names

Date of BirthDD/MM/YYYY

Personal Identification Number

Identification number of the institution

Identification number of the card

Expiry Date

PRC Valid From

PRC Valid To

I have an S1 Form (e.g. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state.)

Please give your S1 form to the practice staff.

How will your EHIC/PRC/S1 data be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process.

Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

Confirm

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.

New Patient Registration Additional Information

Mobile Number

Email Address

Which is your preferred contact method

Are you happy to receive text reminders

Are you happy to receive email reminders

Are you currently a smoker?

Have you ever been a smoker?

If so, how many cigarettes / cigars / tobacco do you smoke per day?

How much alcohol do you drink in a week (Units)?(One unit = 1 small glass of wine, a single measure of spirits, or 1/2 a pint of beer)

How often do you exercise per week?

OccupationThis information is used for vaccine roll out where some workers may need to be offered early vaccination.

Are you a Carer?Only answer yes to this is you care for someone on a non-professional basis. We will therefore refer you for local unpaid carer support.

Would you like to be referred to the social prescribing service?The social prescribing service is free and helps patients to look after their general health and wellbeing.

Summary Care Records - Are you happy to share your NHS Summary Care record with health care staff providing your NHS Care?Your summary care record can be viewed by other health professionals in an emergency situation or to help them provide the most effective care and treatment to you. Your records are treated in line with strict confidentiality requirements for NHS organisations. Opting out of this could have an impact on the care you receive from other NHS services.

Would you like to join our Patient Participation Group (PPG)?The Practice is committed to improving the services we provide to our patients. To do this, it is vital that we involve our patients in our service delivery and design. If you tick yes, we will contact you with more information.

Please provide details of allergies you currently have

Please provide details of any medical conditions you currently have

Please provide details of current physical difficulties / disabilities you have (including if you are sight or hearing impaired)

Current Regular Medication:

Please detail below all regular medication you are currently taking (This includes ANY medication you regularly take including via private prescription or purchased via the internet/store). You will need to provide a repeat slip from your previous practice

If you take Benzodiazepines, Zopiclone or any drugs of dependence, you will be required to comply with the practice reduction program. By continuing with registration, you agree to comply with the practice reduction programme.

Please list any medications including strength and dose

Please nominate a pharmacy so prescriptions can be sent electronically. You can then collect your medication from the nominated Pharmacy

Name and address of nominated Pharmacy:

If you are completing the form on behalf of someone else, please provide your name and relationship to the patient

Spoken Language(s)

Do you require an interpreter?

Practice Policy on Hypnotics and Anxiolytics Pre-Registration Questionnaire

Any new patients currently prescribed hypnotics (sleeping tablets) or anxiolytics included in the list of medicines below, will be placed on a withdrawal regime at the time of registration unless a GP feels this is not appropriate. THIS FORM MUST BE COMPLETED BY ALL PATIENTS WISHING TO REGISTER. FAILURE TO COMPLETE THIS SECTION WILL RESULT IN YOUR FORMS BEING RETURNED TO YOU AND YOUR REGISTRATION DELAYED.

Please choose a) OR b) below

a) I am not currently prescribed or taking any of the following medications: Diazepam, Flurazepam, Loprazolam, Lorazepam, Lormetazepam, Nitrazepam, Oxaepam, Temazepam, Zoplicone, Zolpidem and Zaleplon

b) I am currently prescribed or taking at least one of the following medications: Diazepam, Flurazepam, Loprazolam, Lorazepam, Lormetazepam, Nitrazepam, Oxaepam, Temazepam, Zoplicone, Zolpidem and Zaleplon. By registering with this practice I agree to be started on a withdrawal regime unless the GP feels this is not appropriate

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Accrington Branch • 387-391 Blackburn Road, Accrington, BB5 1RP.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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